Pittsburgh Pain Physician PLLC

Page 1 New Patient Intake Form – Revised Sept 2013  

PITTSBURGH  PAIN  PHYSICIANS  New   Patient   Intake   Form  

 Your completed intake paperwork helps our physicians get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. Please take your time and inquire at our front desk or call (412)533-2202 if you have any questions or are unsure how to complete any section of this form.

Patient  Information  

Today’s   Date _____________________

 

Your   Name: Social  Security  Number:

Street   Address:   Date   of   Birth: Age:

City/State/Zip: Height: Weight: lbs

Email:   Gender:   Male Female  

Physical  Address  Same  as  Mailing?              Yes          No If  not,  

Preferred   Phone:  

Secondary   Phone: Driver’s  License  #/State:  ___________________  

Primary  Care  Doctor:_______________________________ PCP  Phone  #:      

Emergency   Contact   Name: Phone: Relationship:

Marital   Status:   Married Single Divorced   Widowed   Other

Race:   American   Indian   or   Alaskan   Native   Asian   or   Pacific   Islander Black White Refuse   to   Report

Ethnicity:   Hispanic   Non-­‐-­‐-­‐Hispanic Refuse   to   Report Primary   Language: English   Spanish   Other  

Referral    

Were   you   referred   to   our   clinic   by   another   physician?   If   so,   whom? If   not,   how   did   you   hear   about   us?  

Preferred   Pharmacy    

Pharmacy   Name: Phone   Number:  

Street   Address: City/State/Zip:  

Primary   Insurance   Plan    

Payer   (e.g.   BC/BS): Plan:  

Policy/I.D.   Number: Group   Number:  

Complete   this   box   if   you   are   not   the   policy   holder   for   your   primary   insurance  Insurance   policy   holder:   Self Spouse Child Other:

Policy   Holder   Name: Policy   Holder   Gender:     Female   Male

Date   of   Birth: Social   Security   Number:

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Pittsburgh Pain Physician PLLC

Page 2 New Patient Intake Form – Revised Sept 2013  

Pain   Location  

Secondary   Insurance   Plan   (if   any)    

Payer   (e.g.   BC/BS): Plan:  

Policy/I.D.   Number: Group   Number:  

Complete   this   box   if   you   are   not   the   policy   holder   for   your   secondary   insurance    

Insurance   policy   holder:   Self Spouse Child Other:

Policy   Holder   Name: Policy   Holder   Gender:   Female   Male

Date   of   Birth: Social   Security   Number:  

 

Workers   Compensation   Claim  Information  Complete   this   section   only   if   your   visit   today   is   related   to   a   Workers  Compensation   claim  

 Workers   Comp   Company: Agent  Name:

Phone   number: Fax  Number:

Claim   Number: Date   of   initial   injury:  

Pain   Description      

Use   the   pain   scale   described   below   to   rate   your   pain   for   the   questions   below:  0   –   Pain-­‐-­‐-­‐free  1 –   Very   minor   annoyance,   occasional   minor   twinges  2 –   Minor   annoyance,   occasional   strong   twinges 3   –   Annoying   enough   to   be   distracting  4   –   Can   be   ignored   if   you   are   really   involved   in   your  work/task,   but   still   distracting 5   –   Cannot   be   ignored   for   more   than   30   minutes  6   –   Cannot   be   ignored   for   any   length   of   time,   but   you   can   still   go   to   work   and   participate   in   social   activities 7   –   Makes   it   difficult   to   concentrate,   interferes   with   sleep,   but   you   can   still   function   with   effort  8   –   Physical   activity   is   severely   limited.   You   can   read   and   talk   with   effort.   Nausea   and   dizziness   caused   by   pain. 9   –   Unable   to   speak,   crying   out   or   moaning   uncontrollably,   near   delirium  10   –   Unconscious,   pain   makes   you   pass   out  

   

What   number   on   the   pain   scale   (0-­‐-­‐-­‐10)   best   describes   your   pain   right   now?    

What   number   on   the   pain   scale   (0-­‐-­‐-­‐10)   best   describes   your   worst   pain?    

What   number   on   the   pain   scale   (0-­‐-­‐-­‐10)   best   describes   your   least   pain?    

What   number   on   the   pain   scale   (0-­‐-­‐-­‐10)   best   describes   your   average   pain   over   the   last   month?  

Pittsburgh Pain Physician PLLC

Page 3 New Patient Intake Form – Revised Sept 2013  

Use   this   diagram   to   indicate   the   location   and   type   of   your   pain.   Mark   the   drawing   with   the   following  letters that   best   describe   your   symptoms:  

 

 “N”  numbness “S”   stabbing “B”   burning “P”   pins   and   needles  “A”   aching  

                                       Where  is  your  worst  area  of  pain  located?      Does  this  pain  radiate?    If  so,  where?        Please  list  any  additional  areas  of  pain:        

 

Onset   of   Symptoms    Approximately   when   did   this   pain   begin?

 

What   caused   your   current   pain   episode? Is   your   pain   the   result   of   a   Motor   Vehicle   Accident   or   Personal   Injury   (legal   term   describing   injury  sustained   to   your person   by   negligence   of   another)   Yes No  

 

How   did   your   current   pain   episode   begin?   Gradually Suddenly    

Since   your   pain   began,   how   has   it   changed?   Decreased Increased Stayed   the   same    

Pain   Description  Check   all   of   the   following   that   describe   of   your   pain:   Aching Hot/Burning Shooting Stabbing/Sharp Cramping Numbness Spasming Throbbing   Dull ”Shock”-­‐-­‐like Squeezing Tiring/Exhausting Tingling/Pins   and   Needles  

 

What  word  best  describes  the  frequency  of  your  pain?          Constant                Intermittent  (Comes  and  goes)    

When  is  your  pain  at  its  worst?              Mornings            During  the  day            Evenings            Middle  of  the  night                                                                                                                                      With  Activity                PAIN  ONLY  OCCURS  With  Activity  __________________  

Pittsburgh Pain Physician PLLC

Page 4 New Patient Intake Form – Revised Sept 2013  

In  the  past  three  months  have  you  developed  any  new:      

Balance   Problems   Bladder   incontinence   Bowel   incontinence   Chills   Difficulty   Walking   Fevers   Nausea    Vomiting   Numbness/Tingling   –   Where? Weakness   –   Where?

 

I  HAVE  NOT  RECENTLY  DEVELOPED  ANY  OF  THE  ABOVE  CONDITIONS.    

 

Diagnostic  Testing  and  Imaging    Mark   all   of   the   following   tests   you   have   had   that   are   related   to   your   current   pain  complaints:  

 

MRI   of   the Date: Facility:

X-­‐-­‐-­‐ray   of   the Date: Facility:

CT   scan   of   the Date: Facility:

EMG/NCV   study   of   the Date: Facility:

Other  diagnostic  testing:              

I  HAVE  NOT  HAD  ANY  DIAGNOSTIC  TESTS  PERFORMED  FOR  MY  CURRENT  PAIN  COMPLAINTS.  

 

Pain  Treatment  History  Mark  all  of  the  following  pain  treatments  you  have  previous  had  &  percent  of  pain  relief  obtained  with  each:  

       Prior  Pain  Clinics  or  Pain  Physicians:  Where/Who?  

       Physical  Therapy     %  

       Spine  Surgery                                      %  

Chiropractic                                        %  

       Discogram  –  (Circle  type:  Cervical  /  Thoracic  /  Lumbar)                                    %  

       Epidural   Steroid   Injection   –   (Circle  type:  Cervical  /  Thoracic  /  Lumbar)                                      %  

       Nerve  Blocks  –  (Area/Nerves:                                    )                                      %

       Medial  Branch  Blocks  or  Facet  Injections  –  (Circle  type:  Cervical  /  Thoracic  /  Lumbar)                                    %  

       Radiofrequency  Ablation  –  (Circle  type:  Cervical  /  Thoracic  /  Lumbar)                                    %  

       Spinal  Column  Stimulator  –  (Circle  type:  Trial  Only  /  Permanent  Implant)                                    %  

       Joint   Injections  –  (Region:                                                          )                                    %  

       Trigger  Point  Injection  –  (Region:                                                          )                                      %  

       Vertebroplasty  /  Kyphoplasty  –  (Levels:                 )                   %  

    I  HAVE  NOT  HAD  ANY  PRIOR  TREATMENTS  FOR  MY  CURRENT  PAIN  COMPLAINTS.  

Pittsburgh Pain Physician PLLC

Page 5 New Patient Intake Form – Revised Sept 2013  

Past   surgical   history  

 Anesthesia  History  Have   you   ever   had   anesthesia   (sedation   for   a   surgical   procedure)?   Yes   No    

If   so,   have   you   ever   had   any   adverse   reaction   to   anesthesia? Yes No Which   type   of   anesthesia   did   you   react   adversely   to?   Please   check   all   that   apply.   Local   anesthesia Epidural General   anesthesia   IV   Sedation    

Do   you   have   a   family   history   of   adverse   reactions   to   anesthesia?  If  so,  to  which  of  the  following?   Local   anesthesia Epidural General   anesthesia   IV   Sedation  

 Past   Surgical   History  Please   indicate   any   surgical   procedures   you   have   had   done   in   the   past,   including   the   date,   type,   and  any pertinent   details.    Abdominal   Surgery    

   Gallbladder  removal    Appendectomy    Other                                                                                                                                                Female   Surgeries      Caesarean  section                                                                                              Hysterectomy                                                                                                                          Laparoscopy                                                                                                                        Ovarian                                                                                                                                                    Other                                                                                                                                                Heart   Surgery    Valve  replacement                                                                                            Aneurysm  repair                                                                                                  Stent  placement                                                                                                                      Other                                                                                                                                              

 Joint   Surgery    

Shoulder                                                                                                                                 Hip                                                                                                                                                     Knee                                                                                                                                      Spine   /   Back   Surgery      Discectomy  (levels)                                                                                                Laminectomy  (levels)                                                                                              Spinal  fusion  (levels)                                                                                            Other   Common   Surgeries        Hemorrhoid  surgery                                                                                                                Hernia  repair                                                                                                                            Thyroidectomy                                                                                                                              Tonsillectomy                                                                                                                         Vascular   surgery                                                                                                                    

 Please   list   any   other   surgeries   and   dates   (attach   an   additional   sheet   if   necessary)         I   HAVE   NEVER   HAD   ANY   SURGICAL   PROCEDURES   DONE.  BLOOD  THINNING  MEDICATIONS  Please   indicate   which   (if   any)   of   the   following   blood-­‐-­‐-­‐thinners   you   are   taking:        Aspirin/Ecotrin(dose)                                              Aggrenox       Coumadin/Warfarin       Lovenox Plavix       Pletal   Pradaxa       Brilinta              Effient Prasugrel Ticlid                  Indomethacin/Indocin            Volteran/Diclofenac/Arthrotec          Ibuprofen/Advil/Motrin              Naproxen/Aleve            Celebrex/Celcoxib                Mobic/Meloxicam          Piroxicam/Feldene          Xarelto              Other                              

Pittsburgh Pain Physician PLLC

Page 6 New Patient Intake Form – Revised Sept 2013  

CURRENT  MEDICATIONS  Ual   history  

     Please   list   all  medications   you   are   currently   taking.   Attach   an   additional   sheet,   if   required.  

 

Medication   Name Dose Frequency   Medication   Name Dose Frequency        PRIOR  PAIN  MEDICATIONS  THAT  DID  NOT  HELP  PAIN  OR  CAUSED  SIDE  EFFECTS  (INCLUDE  DOSES)          Medication  Name                              Dose                                    Frequency                  Medication  Name                                Dose                                  Frequency    

Pittsburgh Pain Physician PLLC

Page 7 New Patient Intake Form – Revised Sept 2013  

Alcohol   Use:   Daily   Limited  Use   History   of   Alcoholism   Current   Alcoholism     Never   Drinks   Alcohol   Drinks   Alcohol   Socially      

Allergies  Do   you   have   any   known   drug   allergies?                                      Yes No  

 

If   so,   please   list   all   medications   you   are   allergic   to.   Medication   Name Allergic   Reaction   Type

                     

Topical   Allergies: Iodine/Contrast Latex Tape                          Betadine Are   you   allergic   to   shellfish?     Yes No  

 

Family   History  Mark   all   appropriate   diagnoses   as   they   pertain   to   your   biological  MOTHER   AND   FATHER   only.  

 Other   medical   problems:

 

I  HAVE  NO  SIGNIFICANT  FAMILY  MEDICAL  HISTORY.    I  AM  ADOPTED  (No  Medical  History  Available).    

Social   History    Are   you   capable   of   becoming   pregnant?   Yes No If   so,   are   you   currently   pregnant?   Yes No

Highest   level   of   education   obtained: Grammar   school High   School     College     Post-­‐-­‐-­‐graduate  

       

Tobacco   Use: Current   Tobacco   User Packs   Per   Day How   many   years   smoker Former   Tobacco   User Has   Never   Used   Tobacco  

 

Illegal   Drug   Use:     Denies   Any   Illegal   Drug   Use Currently   Using   Illegal   Drugs   (Which: ) Currently   Uses   Marijuana   Currently   Using   Someone   Else’s   Prescription   Medications Formerly   Used   Illegal   Drugs   (not   currently   using)   (Which: )    

Have   you   ever   abused   narcotic   or   prescription   medications? Yes No   (Which:   )    Are  you  working?          Yes          No            Profession?______________________________            Full  Time?          Yes              No      

Pittsburgh Pain Physician PLLC

Page 8 New Patient Intake Form – Revised Sept 2013  

Past   Medical   History  Mark   the   following   conditions/diseases   that   you   have   been   treated   for   in   the   past:  

 

General   Medical      Cancer  –  Type Diabetes–  Type HIV   /   AIDS  

 Head/Eyes/Ears/Nose/Throat   Headaches Migraines Head   Injury   Hyperthyroidism Hypothyroidism Glaucoma    Cardiovascular   /   Hematologic   Anemia   Bleeding   Disorders Heart   Attack   High   Blood   Pressure High   Cholesterol   Mitral   Valve   Prolapse Murmur   Phlebitis   Poor   Circulation Stroke   Coronary   Artery   Disease Pacemaker/Defibrillator  

 Respiratory Asthma Bronchitis  

 

Emphysema   /   COPD Pneumonia   Tuberculosis              Sleep  Apnea  Gastrointestinal        Bowel   Incontinence GERD   (Acid   Reflux)   Gastrointestinal   Bleeding Constipation  

 Musculoskeletal Amputation Bursitis   Carpal   Tunnel   Syndrome   Chronic   Low   BackPain Chronic   Neck   Pain Chronic   Joint   Pain Fibromyalgia   Joint   Injury Osteoarthritis Osteoporosis   Phantom   Limb   Pain Rheumatoid   arthritis Tennis   Elbow   Vertebral   Compression

Fracture    Genitourinary/Nephrology   Bladder   Incontinence  

 

Dialysis/Kidney  Problems          Kidney   Infection(s) Kidney   Stones   Urinary   Incontinence  

 Hepatic   Hepatitis   A  

(active   /   inactive   /   unsure)   Hepatitis   B  

(active   /   inactive   /   unsure)   Hepatitis   C  

(active   /   inactive   /   unsure)    Neuropsychological Alcohol   Abuse Alzheimer   Disease Bipolar   Disorder Depression   Epilepsy   Prescription   Drug   Abuse Multiple   Sclerosis   Paralysis   Peripheral   Neuropathy Schizophrenia   Seizures   Reflex   Sympathetic

Dystrophy/CRPS   Other   Diagnosed   Conditions:  

 

 Review   of   Systems  Mark   the   following   symptoms   that   you   currently   suffer   from.   Note:   Diagnosed   conditions/diseases   should  be noted   under   Past   Medical   History,   above.  

 Constitutional: Chills Difficulty   Sleeping Easy   Bruising Excessive   Sweating Excessive   Thirst Fatigue Fevers   Insomnia Low   Sex   Drive Night   Sweats Tremors Unexplained   Weight   Gain   Unexplained   Weight   Loss     Weakness  

 Eyes: Recent  Visual  Changes            Glaucoma    Ears/Nose/Throat/Neck: Dental   Problems Earaches Hearing   Problems Nosebleeds Recurrent   Sore   Throats Ringing   in   the   Ears Sinus   Problems

Pittsburgh Pain Physician PLLC

Page 9 New Patient Intake Form – Revised Sept 2013  

 

Cardiovascular: Bleeding   Disorder   Chest   Pain   Deep   Vein   Thrombosis   Fainting   High   Blood   Pressure   Irregular   Heartbeat   Lightheadedness   Shortness   of   Breath   During   Sleep Swelling   in   the   Feet  

 Respiratory: Cough Wheezing Pulmonary   Embolism Shortness   of   Breath   on   Exertion/Effort Shortness   of   Breath   at   Rest  

 Gastrointestinal:   Abdominal   Cramps   Acid   Reflux   Constipation   Coffee   Ground   Appearance   in   Vomit   Dark   and   Tarry   Stools   Diarrhea   Hernia   Vomiting      

 

Musculoskeletal:   Back   Pain   Joint   Pain   Joint   Stiffness   Joint   Swelling   Muscle   Spasms   Neck   Pain    

 

Genitourinary/Nephrology:   Blood   in   Urine    

Decreased   Urine   Flow/Frequency/Volume   Flank   Pain   Painful   Urination    

Neurological: Carpal   Tunnel   Syndrome           Instability  When  Walking   Headaches Numbness/Tingling Dizziness             Tremors         Seizures  

 Psychiatric:   Depressed   Mood   Feeling   Anxious   Stress   Problems   Suicidal   Thoughts   Suicidal   Planning      

Medical   History   and   Consent   for   Treatment  I   certify   that   the   above   information   is   accurate,   complete   and   true.  

 

I   authorize   Pittsburgh  Pain  Physicians   and   any   associates,   assistants,   and   other   health   care   providers   it  may   deem necessary,   to   treat   my   condition.   I   understand   that   no   warranty   or   guarantee   has   been  made   of   a   specific result   or   cure.   I   agree   to   actively   participate   in   my   care   to   maximize   its  effectiveness.  

 

I   give   my   consent   for   Pittsburgh  Pain  Physicians   to   retrieve   and   review   my   medication   history.  I  understand   that this   will   become   part   of   my   medical   record.  

 

I   acknowledge   that   I   have   had   the   opportunity   to   review   Pittsburgh  Pain  Physicians’   Notice   of   Privacy  Practices, which   is   displayed   for   public   inspection   at   its   facility   and   on   its   website.   This   Notice  describes   how   my protected   health   information   may   be   used   and   disclosed,   and   how   I   may   access  my   health   records.  

 

I   authorize   the   Pittsburgh  Pain  Physicians   to   release   my   Protected   Health   Information   (medical  records)   in accordance   with   its   Notice   of   Privacy   Practices.   This   includes,   but   is   not   limited   to,  release   to   my   referring physician,   primary   care   physician,   and   any   physician(s)   I   may   be   referred   to.   I  also   authorize   Pittsburgh  Pain  Physicians   to   release   any   information   required   in   obtaining   procedure  authorization   or   the   processing   of   any insurance   claims.  

 

I   understand   that   Pittsburgh  Pain  Physicians   will   not   release   my   Protected   Health   Information   to   any  other   party (including   family)   without   my   completing   a   written   “Patient   Authorization   for   Use   and  Disclosure   of   Protected Health   Information”   form,   available   at   its   facility   and   on   its   website.  

     

Signed: Date: